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Tiru - Bloomstone (3123) Radial Artery Cannulation: A Review Article. J Anesth Clin Res 4:31:. doi:21.528303266- Page 2 of 6 the current “Allen” test [13]. Caution however must be exercised with patients who are more likely to have vascular disease and those who are radial artery dominant. Anatomye increased use of the radial artery in coronary artery bypass graing has generated new interest in its anatomy. In most patients, the artery originates just below the elbow as a branch of the brachial artery. e radial artery courses passes along the lateral margin of the forearm until it reaches the level of the wrist [14]. In the upper forearm the vessel is deep to the body of the supinator longus muscle. In the mid forearm, down to the level of the wrist, it lies between the tendons of the supinator longus and the exor carpi radialis (Figures 1 and Figure Variations in both the origin and course are well described [15].e most common variant involves the artery originating just superior to the elbow, although it may originate much higher in the arm. High origination from the brachial artery has been reported in up to 12% of cases [14-17] while 5% of humans have its origination within the axilla [18]. ere have been described cases of patients with dual radial arteries [17,19-21] or absence of radial artery [22-26].e radial artery is usually smaller than the ulnar artery at their origins [17,27], but is equal or larger at the wrist as the ulnar artery gives o numerous branches in the forearm [28]. Together the two arteries create a dense anastomotic network of 4 arches, providing arterial blood ow to the hand. ree of these arches occur on the palmar side of the hand and include the palmar carpal arch, the deep palmar arch, and the supercial palmar arch (Figure 3). e arterial network on the dorsal side consists of the dorsal palmar rete. e palmar arches can be divided into 2 types: complete and incomplete [29]. e supercial palmar arch (formed from the terminal part of ulnar artery) and deep palmar arch (formed from the terminal part of radial artery) [14,30] are the most clinically signicant arches because they provide blood ow to all the digits of the hand. e majority of individuals have either a complete supercial or a deep palmar arch, which makes radial artery occlusion well tolerated. When radial artery occlusion occurs in a patient with 2 incomplete arches the risk for digital ischemia is substantially increased [31]Indications for CannulationIntra-arterial cannulation with continuous blood pressure transduction is considered the most accurate method for blood pressure monitoring by most clinicians. Arterial cannulation is most oen performed when either continuous blood pressure measurement is needed and/ or frequent arterial blood gas sampling is required. Recently, functional hemodynamic parameters derived from the arterial waveform–pulse pressure variation (PPV), systolic pressure variation (SPV) or pulse contour analysis–stroke volume variation (SVV) to better predict the physiologic response to uid resuscitation or uid removal have been described. [32,33]Other uses for arterial cannulation are related to inability to use/inaccurate regular blood pressure monitoring (e.g., severe burns, morbid obesity, and severe peripheral vascular disease). ContraindicationsAbsolute contraindications to radial artery cannulation include inadequate circulation to the extremity, Raynaud syndrome, thrombo A. metacarpalisdorsalisRr. perfor-Right middle finger, lateral viewAnterior (palmar) view.MembranainterosseaantebrachiiA. ulnaarls(r.carpalis dorsalis)Dorsal carpalnetworkAa.digitalesdorsales Figure 2: Arterial circulation of the hand. A. right middle �nger- lateral view. B. Anterior (palmar) view. C. Posterior (dorsal) view. (reproduced with permission from Atlas of Anatomy- Gilroy AM- MacPherson BR- Ross LM (311:) Thieme Medical Publishers- New York- NY) Tiru - Bloomstone (3123) Radial Artery Cannulation: A Review Article. J Anesth Clin Res 4:31:. doi:21.528303266- Page 3 of 6 angiitis obliterans (Buerger disease), and full-thickness burns or skin infection over insertion site.Other contraindications are relative, such as uncontrolled coagulopathy, systemic anticoagulation, inadequate collateral ow from ulnar artery on Allen test, or atherosclerosis [34,35].ComplicationsIn a review by Scheer et al. [36], the most common complications were temporary radial artery occlusion (19.7%), and hematoma (14.4%) followed by infection at the arterial site (0.72%), hemorrhage (0.53%) or bacteremia (0.13%), and very rarely permanent ischemic damage or pseudoaneurysm (0.09% each). Local injury (e.g., intimal damage and proliferation) and scarring have been found even aer short term catheterization. Long-standing or permanent radial artery occlusion has also been described. In some cases (particularly aer vascular procedures) the radial artery occlusion may be delayed several days of the procedure or removal of catheter er &#x/MCI; 23; 00;&#x/MCI; 23; 00;Rare complications include paralysis of the median nerve [38-40] air embolism [41], compartment syndrome, and carpal tunnel syndrome [42-44]. Rarely, intravascular catheter fragments have occurred d &#x/MCI; 24; 00;&#x/MCI; 24; 00;Larger catheter diameter [37,49,50], presence of vasospasm [37,51-53], female sex [52,54] (probably related to smaller vessel diameter) [37,50,54,55] increase the risk of ischemic complications. Inadequate experience placing catheters (high number of attempts, multiple arterial sticks and hematoma formation) may inuence the complication rate e &#x/MCI; 25; 00;&#x/MCI; 25; 00;Pre-Procedure AssessmentStep 1Consider indications for arterial catheterization, anticipated catheter duration and presence of risk factor.Step 2Inspect potential areas of cannulation looking in particular for signs of infection, skin breakdown, accessibility, and importantly the presence of the radial pulse. e physical examination should include at least a bilateral evaluation of pulse quality and of the blood pressure in both arms. e quality of the pulse and noting whether a blood pressure dierential exists will provide important clues to both the ease of arterial cannulation as well as the accuracy of the measurement. Step 3In the case of radial arterial cannulation, one must assess for the presence of an ulnar dominant blood ow to the hand. Numerous studies have investigated the use of the Allen’s test [12], the modied Allen’s test [13], pulse oximetry, and Doppler ultrasound.Allen described a method to assess the collateral circulation of the hand in patients with thromboangiitis obliterans. e test consists of the compression of either the radial or ulnar artery while the patient clenches the st for approximately 1 minute [12]. e patient then unclenches the st while pressure over the vessels (radial or ulnar) is maintained and return of color to the hands and ngers is noted. Normally the pallor quickly disappears if the circulation is intact [56].Performing the modied Allen’s test requires compression of both “the ulnar and radial arteries at the wrist for greater than 30 seconds to induce hand ischemia, while the hand is drained of blood by tight clenching. e test vessel is released and the hand relaxed. e time to adequate perfusion of the tips of the ngers and thumb noted. e vessel is said to pass or fail the test as follows: pass (seconds); equivocal (6 -10 seconds); fai 40;l (10 seconds)” [57]. Erroneous results can arise if the test is performed incorrectly with the hand hyperextended or wide spreading of the ngers [58,59]. Both tests suer from inter-observer reliability issues and have not been validated to be predictive of hand ischemia aer radial artery cannulation [29], therefore the use of Allen’s or modied Allen’s test is not widely accepted. When performed, any failure of the tested vessel should prompt the provider to document the abnormal nding and to use an alternate site for cannulation.Pulse oximetry was used to make the interpretation of modied Allen’s test more reliable, but results were not promising [60-62].e utilization of ultrasound or Doppler ultrasound to facilitate both cannulation and integrity of collateral circulation is promising, but has not been rigorously evaluated [29]. Techniquee procedure should be explained to the patient and informed consent should be obtained when possible. Appropriate sedation and analgesia are important for patient cooperation and comfort. e needed equipment and supplies (Table) should be gathered. e patient’s wrist is hyperextended and held in place with an arm board and gauze dressing so that the wrist is exposed (Figure 3). Positioning of the patient’s arm and wrist is one of the most important preparatory steps as hyperextension of the wrist brings the radial artery more supercial and increases success rate [35]. e Center for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) updated guidelines [63] for the prevention of intravascular catheter-related bloodstream infections in 2011, suggest the use of a cap, mask, sterile gloves and a small fenestrated drape (as a minimum) to help reduce the risk of infection.Once the wrist is extended and xed to an arm board with tape or gauze, a chlorhexidine  40;( 0.5%) or iodinated wash is performed (Figure and a large sterile eld is applied over the wrist area (Figure 5). e artery is then palpated between the rst and second ngers (Figure 6).Alternatively the use of ultrasound to nd the radial artery increases success, decreases procedure time [64-68], and minimizes the number of needle passes. Wrist is hyperextended with the use of an arm board and a roll. Tiru - Bloomstone (3123) Radial Artery Cannulation: A Review Article. J Anesth Clin Res 4:31:. doi:21.528303266- Page 4 of 6 e entry site is typically 1-1.5 cm cephalad from the junction of the arm and the hand. Typically the best approach is to nd the area of maximal arterial pulsation. A 20-gauge or smaller catheter over the needle cannulation is typically used with or without a guide wire ure 7). Once pulsatile blood ow is noted the catheter should be gently slipped into the artery with a slight rotation while holding the needle perfectly still. If a guide wire is to be used at this point, it should now be inserted through the needle into the vessel and the catheter advanced over it (over-the-wire technique) (Figure 8). Occasionally the back wall of the artery is penetrated. In this circumstance, the pulsatile ow will be transient. Simply backing the needle catheter assembly out slowly and assessing for the return of pulsatile blood ow will oen locate the vessel in this situation. Patency of radial artery catheters is enhanced by placing the catheter close to the bend of the wrist [69]. e catheter should then be hooked up to the pressure tubing, quickly ushed and the adequacy of the arterial trace assessed for optimal damping. e catheter should be secured using tape, or other securing devices such as Stat Lock [70]. e 2011 CDC guidelines recommend against the suturing of catheters [63].If cannulation fails, there may be anatomic or technical problems why the vessel cannot be entered. Radial artery cannulation is associated with a very high success rate, thus several failed attempts should prompt the provider to try another site. e use of ultrasound has been shown to increase the success of rst cannulation attempt from 27% to o &#x/MCI; 37; 00;&#x/MCI; 37; 00;Monitoring of site / Care of the arterial siteSpecial care should be exercised aer successful insertion of the arterial catheter to assure that the site, ushing device, and infusion system is free of contamination [71-73]. e risk of arterial catheter infection appears to be lower than that of central venous catheters, although the rate of colonization is the same [74]. Current CDC guidelines recommend against routine replacement of arterial catheters [63], although immune compromised patients may benet from routine catheter change every 4 days [75].Although there is some advantage to the use of heparin (in dierent concentrations) versus heparin-free ushing solutions in preventing catheter occlusion [76-78] many ICUs have moved away from using heparinized solutions due the risk of heparin induced thrombocytopenia [79-82] and falsely abnormal coagulation proles [83-85].e arterial access should be removed as soon as it is no longer needed or when there is evidence of circulatory compromise or clot formation (e.g. cyanosis in ngers tips, dampening pulse waveform on monitor). e catheter should not be ushed in an attempt to remove clots. Vigorous ushing of the catheter should be avoided, as rare cases of cerebral embolization have been reported [86,87].Aer removal of catheter, hemostasis is usually achieved with compression over the arterial site. Although there are commercially available compression devices (i.e. RadStat, Radistop, Adapty, TR band, etc) [88], simple manual site compression with gauze secured with tape is sucient. SummaryRadial artery catheterization is a common, safe and important procedure in the care and management of both the critically ill and the high risk surgical patient. Relevant anatomy and attention to detail during cannulation and maintenance of the catheter are important aspects of the technique which enhance patient safety. Although minimally Figure 4: Figure 5: A large enough drape is applied over the prepped area. Figure 6: Figure 7: Catheter needle assembly is held at 56 degrees- while artery is pal Figure 8: Guide wire is advanced in the artery after blood is seen advancing in the catheter needle assembly. Tiru - Bloomstone (3123) Radial Artery Cannulation: A Review Article. J Anesth Clin Res 4:31:. doi:21.528303266- Page 5 of 6 invasive and non-invasive techniques for the measurement of blood pressure and arterial oxygenation abound, intra-arterial cannulation remains vital to the care and management of both critically ill patients in the ICU and those going to the operating theater.Dr. Tiru: concept- review of the literature- primary authorship- and composition Dr. Bloomstone: review and editingDr. McGee: concept- review- and editing Hales S (2851) Statical Essays: containing hemastatics: or- an account of some hydraulic and hydrostatical experiments made on the blood and blood-vessels of animals To which is added- an appendix- With an index to both vs Vol II The Booth J (2:88) A Short History of Blood Pressure Measurement. Proc R Soc A (2:66) Development of apparatus and methods for roentgen studies in haemodynamics. Acta Radiol Suppl 241:8–81. 4. 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